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The U.S. Department of Veterans Affairs (VA) is responsible for meeting the government’s obligation to provide health care to American veterans. However, not all veterans are eligible for VA care. Furthermore, VA-eligible veterans often use multiple sources of care, including care paid for by VA but delivered by non-VA providers and care that veterans buy on their own from private providers. Thus, private-sector providers are an increasingly important part of the workforce to care for veterans, who are a clinically complex population with higher rates of some mental health and chronic conditions and elevated rates of suicide compared with the general population.
Three aspects of provider capabilities were addressed in our assessment:
- Timely care. Are providers accepting new patients and can patients get an appointment within two weeks?
- Culturally competent care. Are providers familiar with military culture, and how might this shape veteran preferences for care?
- High-quality care. Do providers regularly screen for conditions, such as suicidal ideation, that are more common among veterans than among the general population, and do providers follow evidence-based guidelines?
Provider Familiarity with Military Culture Is Uneven
Familiarity with military culture can help providers understand how a veteran’s background contributed to his or her current medical condition and can contribute to the development of a good provider-patient relationship. Yet only 19 percent reported regularly asking patients about their military service history and only one in three providers met a minimum threshold for familiarity with military culture. Mental health care providers were the most likely to be knowledgeable about various aspects of military and veteran culture, while physician assistants and nurse practitioners were the least likely to report familiarity.
Quality of Care Varies
We asked how often community-based providers screen for specific health concerns that are common among veterans (e.g., sleep-related problems, pain-related concerns, physical impairments). We found that only 43 percent of providers reported routinely conducting such screenings. However, 70 percent of providers reported using clinical practice guidelines — an indication of using evidence-based care — to inform their treatment decisionmaking.
Access to Timely Care Is Not a Major Concern
Almost all of the New York providers reported accepting new patients.
Most reported that new patients could get a visit within two weeks of calling to schedule an appointment.
Nearly half indicated that most patients could get a same-day appointment. If these reports hold true in practice, then access to timely health care in the community should not be a major concern for New York veterans.
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We considered seven dimensions of high-quality care and imposed a series of thresholds in a step-wise fashion to assess overall provider readiness to deliver timely, culturally competent, high-quality care. While 92 percent of New York health care providers were accepting new patients, only 2.3 percent met all seven of the threshold criteria.
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Steps Needed to Improve Private Providers’ Readiness to Treat Veterans
1. Increase Familiarity with and Preparedness Related to Military Culture and Service-Connected Health Conditions
Although there have been many campaigns and programs aimed at teaching providers about military culture, participation rates have been low — roughly 12 percent. In addition, our study found that completing a program did not ensure that providers became culturally competent. Imposing post-training testing to demonstrate cultural competency could address this problem. To this end, some organizations that are focused on increasing competency have discussed how to incorporate appropriate questions into either medical board or state licensing and certification exams as a means of incentivizing providers to learn the material.
2. Improve Screening
Less than half of providers reported that they regularly screened for conditions, exposures, or other clinical and functional issues that are common among veterans. Screenings should also be expanded to include questions about current or prior military affiliation and appropriate follow-up screenings for potential service-connected health issues that need attention. As new educational campaigns are considered for improving screening, these campaigns can expand the set of questions. It is not enough to ask simply about current or prior military affiliation: Additional questions will be needed to ensure that veterans’ health issues are identified and managed appropriately.
3. Improve Engagement with VA and Available Resources for Veterans
As VA and Congress continue discussions about the potential expansion of care in the community for veterans, it will be essential to consider these findings.
While the focus of the care purchased by VA but delivered in the community has been mostly to facilitate referrals from VA out to the community, there are times when community-based providers need to refer eligible patients back to VA. Yet most (72 percent) of New York health care providers did not know how to refer a patient to VA. Similarly, only one in five was aware of the VA community care programs or had treated VA patients. To ensure continuity and coordination across sectors, efforts will be needed to increase awareness among community- based providers as well as among VA providers about how best to share information and refer patients.
Strategies to increase awareness should include specific information about the type and quality of the services delivered by VA. It will be particularly important to assist community providers in recognizing when a patient might benefit from referral to VA or another care provider in the community with specific capabilities. As VA continues to engage with third-party administrators to coordinate care with private providers (such as in the Veterans Choice Program), this information can be incorporated into provider toolkits and resource materials.
4. Institute Quality Monitoring
A system for monitoring and managing quality among community providers caring for veterans would allow assessment of provider capacity and readiness on an ongoing basis. This system would identify areas of strength and opportunities for improvement, and could inform decisions to include or exclude providers from the VA Community Care provider network. VA may wish to impose its internal monitoring and management standards on the third-party administrators who manage their purchased care networks.
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This study is the first to assess the readiness of non-VA health care providers to provide timely, culturally competent, high-quality care for veterans. Most health care providers in New York report being able to provide timely care and follow clinical practice guidelines; however, most reported knowing little about the military or veterans, not routinely screening for conditions common among veterans, and not being familiar with VA or initiatives to expand access to community-based care for VA-enrolled veterans. Training programs to increase providers’ military cultural competence and knowledge of VA, as well as efforts to incentivize providers to screen veterans for common service-connected conditions, could improve the readiness of health care providers across the state. As VA and Congress continue discussions about the potential expansion of care in the community for veterans, it will be essential to consider these findings to determine whether veterans will receive the same level of care they have been provided within VA facilities.